Provider Demographics
NPI:1811907884
Name:WILLIAMS, DEREK JAMES (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:JAMES
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 256
Mailing Address - Street 2:
Mailing Address - City:CLANCY
Mailing Address - State:MT
Mailing Address - Zip Code:59634-0256
Mailing Address - Country:US
Mailing Address - Phone:406-461-0875
Mailing Address - Fax:
Practice Address - Street 1:204 WINSLOW ROAD
Practice Address - Street 2:
Practice Address - City:CLANCY
Practice Address - State:MT
Practice Address - Zip Code:59634
Practice Address - Country:US
Practice Address - Phone:406-461-0875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10496207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT72539Medicaid
MT72539Medicaid
I03070Medicare UPIN